Stuff to memorize for pulm Flashcards
Name the 4 criteria for characterizing exudates.
Hint- 1 involves total protein, 2 involve LDH, and 1 involves chol.
TPpl/TPserum > 0.5, or
LDHpl/LDHserum > 0.6, or
LDHpl > 200 (or 2/3 upper normal)
Cholesterolpl > 45
(last 2 are part of the “revised criteria”)
What criteria do you need to dx an empyema? (1 of these 3)
+ Gram Stain
+ Culture
Pus
Risk factors for obstructive sleep apnea? (7)
Risk factors for central sleep apnea? (2)
Obstructive Sleep Apnea:
- Obesity
- Neck Circumference (>17 in)
- Hypertension
- Male Gender
- Increasing Age
- Smoking
- Retrognathia
Central Sleep Apnea
- CHF
- CNS Disease
Orange cells on PAP stain is characteristic of what cancer?
SQC
Highest frequency mutations in SQC?
p53
TTF-1 is positive in what cancer?
Adenocarcinoma
What are the 3 driver mutations of adenocarcinoma, and the specific drug that can target each?
Adenocarcinoma? EAK! (pussies: girls, nonsmokers) E EGFR (erlotinib) A ALK (crizotinib) K KRAS (none)
What 2 mutations are seen in 100% of SCC cases?
p53 (smoking)
RB
How do you manage a pt w/low pressure pulmonary edema?
1) Fix the underlying problem
*Lower the hydrostatic pressures (even though it’s not high)
- Dry pt out, lower preload as low as CO maintained
- Oxygen (but recognize that this is shunt)
- Mechanical Ventilation
High PEEP
Low tidal volumes
- Salvage therapy- ECMO
What are 2 effective treatments for pulmonary HTN? What drug class is effective in 10% of pts? Why should vasodilators be avoided?
- Pulmonary rehabilitation (exercise, etc).
- Oxygen if needed.
~10% of patients can have a response to calcium channel blockers
- All other vasodilators cause systemic hypotension before pulmonary vasodilation.
Acute sinusitis is a clinical dx. What sx are present?
Congestion, sinus tenderness, fevers, purulent nasal drainage
Most incidents of acute sinusitis are viral. What abx are indicated if there is strong evidence of bacterial sinusitis?
Ampicillin or amoxicillin or trimethoprim-sulfamethoxazole or amoxicillin-clavulanate
Most incidents of acute sinusitis are viral, but when bacterial, what bacteria are most common?
S pneumonia, H. influenza, Moraxella and oral anaerobes
Why do you treat strep throat (caused by GAS/GBS)?
Treatment prevents the complications (rheumatic fever and post strep glomerulonephritis) but does not change the course/duration of the pharyngitis itself.
The most common etiologic organisms in epiglottitis are:
Haemophilus influenzae, Group A strep, and Haemophilus parainfluenzae
(Fortunately with immunization of infants against influenza B, epiglottis is being seen less commonly)
What tx’s (abx) are recommended for epiglottitis?
Emergent evaluation by an otolaryngologist to assess and secure the airway;
Antibiotic therapy: amoxicillin-clavulanate or ampicillin-sulbactam or 3rd generation cephalosporin
What are the sx of PNA?
Cough, sputum production, shortness of breath and fever
Elderly may p/w AMS
What is the #1 cause of typical CA-PNA?
What sx do pts p/w?
Streptococcus pneumoniae
Fever, shaking chills (it may be a single chill), RUSTY COLORED SPUTUM, SOB, and pleuritic chest pain.
(Remember S. pneumoniae appear as lancet shaped diplococci on gram stain)
What are some insidious organisms that can cause chronic PNA?
- Slow growing organisms (Mycobacterium, Nocardia, Actinomyces)
- Endemic fungi (Histoplasmosis, Blastomycosis, Coccidiomycosis)
- Coxiella
- Tularemia
(an anatomic problem (obstructed airway))
Organisms that cause typical CA-PNA?
Strep pneumoniae
H. influenza,
Moraxella catarrhalis
Staphylococcus aureus
Drugs to treat typical CA-PNA?
(outpatient?)
(outpatient w/recent abx or comorbid illness?)
(Inpatient?)
- Outpatient: Macrolides or doxycycline
- Outpatient recent antibiotics or comorbid illness: Respiratory fluoroquinolone
- Inpatient: macrolide + beta lactam
(*at least 5 days tx)
Organisms that cause atypical CA-PNA?
Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella
Drugs to treat atypical CA-PNA?
-Macrolide or -Doxycycline or -Respiratory fluoroquinolone
Organisms that cause HA-PNA?
Gram-neg rods:
- Klebsiella pneumoniae
- E coli
- Enterobacter
- Proteus
- Serratia
- Pseudomonas
- Acinetobacter
MRSA
Drugs to treat HA-PNA?
What if MRSA is suspected?
-Antipseudomonal cephalosporin or -Antipseudomonal carbapenem or -Beta lactam-beta lactamase
If MRSA suspected Vancomycin to be added
What general types of bugs can cause aspiration PNA?
Mix of gram negative aerobes and anaerobes
Drugs to treat aspiration PNA?
-beta lactam + beta lactamase
or
- 3rd generation cephalosporin + metronidazole
What general types of bugs can cause abscess PNA?
Polymicrobial: anaerobic mouth organisms (bacteroides, fusobacterium, peptostreptococcus),
aerobic and anaerobic streptococcus
gram negative rods
Drugs to treat abscess PNA?
-Piperacillin-tazobactam
or
-Clindamycin
(*Duration of therapy is prolonged (up to 4-6 weeks))
What defines severe sepsis?
Sepsis plus evidence of NEW end organ hypoperfusion:
Elevated lactate ≥ 2.1 mmol/L
AKI
- UOP<0.5cc/kg/hr for 2 hrs
- Cr > 2 mg/dL
Hypotension
- SBP < 90 mmHg
- MAP< 65 mmHg
- SBP > 40 mmHg from baseline
Acute respiratory failure
- Need for intubation or non-
invasive ventilation
Coagulopathy
- PTT > 60 sec
- INR > 1.5
- Platelets < 100,000
Bilirubin > 2 mg/dL
Do not include organ dysfunction that is due to chronic condition or medication
Summarize the initial, 3 hour, 6 hour, and 1 additional thing for the mgmt of sepsis.
- Recognize sepsis
- Support airway; breathing
- 3 hour bundle: cultures; serum lactate; broad spectrum abx; IVF if hypotensive or lactate >4mmol/L
- 6 hour bundle: vasopressors if pt remains hypotensive despite fluids; repeat lactate if elevated; pt reassessment
- Consider steroids if hypotensive despite fluids and pressors
In obstruction, what are the parameters that indicate that an obstruction is reversible w/bronchodilator therapy? (2)
Bronchodilator –> ^ FEV1 ’s by 200cc AND 12%
not referring to ratio here
Give the Goljian age ranges for the different leukemias/lymphomas.
ALL = 0-14 AML = 15-39; 40-59 CLL = 60+ CML = 40-59
What are the sx of multiple myeloma?
CRAB
hyperCalcemia, Renal insufficiency, Anemia, Bone lesions
Describe the 3 phases of ARDS
ARDS phases
- Early Exudative Phase (Acute; protein-rich fluid leakage)
- Subacute Proliferative Phase (Organizing of hyaline membranes)
- Fibrotic Phase (Late)
What are the causes of interstitial lung diseases?
SHIT FACED Sarcoid Hypersensitivity Pneumonitis Idiopathic Pulmonary Fibrosis/“IIP’s” Tuberculosis
Fungal Aspiration / Asbestosis Connective Tissue Diseases / (Cancer) Eosinophilic Granuloma Drugs: Amiodarone, Nitrofurantoin, Bleomycin
What 4 values are used to classify the different severities of asthma?
- Daytime symptoms/wk
- Nighttime symptoms/mo
- FEV1 or PEFR
- PEFR variability
What is considered the major “predisposing factor” for non-TB Mycobacteria?
Structural lung abnormality
What 4 criteria define systemic inflammatory response syndrome? (SIRS)
- Temperature: > 38°C or < 36°C
- RR: >20 breaths per minute or pCO2 < 32 mmHg
- Heart rate: > 90 bpm
- WBC count: >12,000 or <4,000 or >10% bands
In sepsis, under what 2 circumstances would you administer IV fluids?
What is the recommended amount? (per kg)
Hypotensive of lactate < 4
30mL/kg
1st choice vasopressor for sepsis?
NE
(2nd: epi or vasopressin)
*But these are only given in 6 hr bundle, if pt remains hypotensive despite fluids
What are the organisms that can cause acute bronchitis?
Mycoplasma
S. pneumoniae
H. infuenzae
Bortadella pertussis
What is the usual tx for acute bronchitis?
Supportive! (because it’s usually viral)
